Mental Health Referral Form (Page 2 of 2) in pdf

Mental Health Referral Form Page 2

CONTACT PERSON TO SET UP APPOINTMENT:

Name:

Phone (day):

Phone (h):

Email:

Relationship to client

OK to leave a message at this phone # from PYCD staff

Parent/guardian is aware of consult

(If yes, parent/guardian Email:

CURRENT MENTAL HEALTH AND SUBSTANCE USE CONCERNS:

_____________________________________________________________________________________________

Previous psychiatric assessment (please attach)

Attach recent laboratory results

Physical health issues__________________________________________

CURRENT MEDICATIONS:

No medication

Attach pharmanet medication list

SERVICE PROVIDERS INVOLVED:

Alcohol & Drug Counsellor:

*While awaiting assessment with PYCD, please consider

referral to Addiction services for additional resources. Call 1-800-663-1441 or 604-660-9382 in the lower mainland.

Mental Health Team Clinician: ________________________________

Ministry for Children & Family Development Social Worker:

Psychiatrist: _________________________________

As lack of collateral information can delay the intake process, please send all consultation reports including psychiatric

consults, mental health consults, addiction services reports, community health service reports, acute care admissions,

emergency department consults, etc.

Signature of Referring Physician

______________________________________________________________

*PLEASE FAX THIS COMPLETED FORM TO: 604-875-2099

bcmhsus.ca | Provincial Youth Concurrent Disorders Program, 5

Floor, Building 77, 4500 Oak Street, Vancouver, BC V6H 3N1

Tel: 604.875.2345 Ext 5332 | Fax: 604.875.2039 Intake Fax: 604.875.2099

Revised: 9/19/2014

Mental Health Referral Form Page 2